Reason Magazine - Staff

Cry the Beloved Continent

melindaammann@hotmail.com (Melinda Ammann) — Fri, 01 Jul 2005 00:00:00 EDT

The Agony and the Ecstasy

melindaammann@hotmail.com (Melinda Ammann) — Tue, 01 Apr 2003 00:00:00 EST

William E. Hurwitz spent much of last year trying to find new doctors for his patients. It wasn't easy, since physicians often are reluctant to treat chronic pain. They worry that repeated prescriptions for large doses of narcotic painkillers will attract unwanted attention from the government. That anxiety was the main reason Hurwitz had ended up treating so many people for pain -- about 300 patients suffering from cancer, rheumatoid arthritis, degenerative disc disease, diabetic complications, and other painful conditions. Some of them had searched for months or years, growing increasingly desperate, before finding him. Many lived hundreds of miles from his Northern Virginia office.

Hurwitz's retirement was not exactly voluntary. A veteran of battles with state regulators and the Drug Enforcement Administration (DEA), the 57-year-old internist saw more trouble on the horizon. After learning that he had been targeted by a federal grand jury investigation of prescription drug diversion, he decided to gradually transfer his patients rather than put them at risk of suddenly losing access to pain medication.

Hurwitz was still working to match patients with new doctors in November, when the DEA raided his home and office. "There are patients in Vermont, Massachusetts, Maine, Connecticut, West Virginia, Virginia, Kentucky, Tennessee, North and South Carolina, and Florida for whom possible referrals are needed," he said in a written statement. In the raid, DEA agents "took patient files, financial and other records, my cell phone, and miscellaneous items. They also copied the hard drives on many of my computers and took my server, as they did not have the equipment to copy this in the office. Fortunately, I had backup files and was able to re-establish my computer network and resume patient care."

But the raid reinforced Hurwitz's concern about his patients' future. "The stigma that these people suffer, both as pain patients on opioid medications in general and as former patients of accused doctors in particular, tends to foreclose most opportunities for effective continuing care," he said last August in a written statement that announced he would be closing his practice. Last summer one of his patients told The Washington Post, "If I go to a doctor and mention [Hurwitz's] name, they won't even touch me. All I'm concerned about is getting rid of this excruciating pain." Another said: "I don't know what I'm going to do. While the criminals who are diverting the drugs get jailed, the innocent patients get the death penalty."

Facing the prospect of criminal prosecution after two regulatory actions against him, Hurwitz certainly understood why doctors are leery of pain patients. Hurwitz lost his state medical license and his federal prescribing privileges in 1996 after the Virginia Board of Medicine and the DEA accused him of excessive prescribing. (See "No Relief in Sight," January 1997.) More than 50 of his patients testified on his behalf at the board's hearing, and pain experts came to his defense, describing the large doses of narcotics he prescribed as reasonable and appropriate. His Virginia license was restored in 1997, and in 1998 he resumed his practice after the DEA reinstated the registration that allows doctors to prescribe controlled substances.

Four years later, however, Hurwitz was giving up. "These aggressive and ill-informed prosecutions convey a message of intimidation to doctors and indifference to the plight of patients in pain," he said in his August statement. "Not even the most honest and competent doctors can practice pain medicine with any assurance of safety for themselves or continuity of care for their patients."

The OxyContin "Epidemic"

The focus of the investigation that finally convinced Hurwitz to stop practicing medicine was OxyContin, a drug that in recent years has been portrayed as a seductive, deadly menace. The news media have advertised its "heroin-like high," generating interest among drug users and alarm among politicians. U.S. Rep. James Greenwood (R-Pa.), who held hearings on the subject in August 2001, asserted that "OxyContin is to prescription drug pain relievers what jet fuel is to unleaded gasoline." That year the Food and Drug Administration (FDA) slapped a "black box warning" onto OxyContin declaring that it has "an abuse potential similar to morphine." The DEA has identified OxyContin as "a major drug of concern," putting it alongside Ecstasy, cocaine, heroin, methamphetamine, and marijuana. Attention from the government has triggered more press coverage, which in turn has egged on drug warriors who are convinced we are in the midst of an "OxyContin epidemic."

For Hurwitz's former patients and other people in pain, OxyContin is not an agent of a metaphorical disease; it is a medication that helps relieve the suffering caused by their all-too-real illnesses and injuries. Introduced by Purdue Pharma in 1995, OxyContin is a 12-hour, timed-release form of oxycodone, a synthetic opioid that has long been available in products such as Percocet, Percodan, and Tylox. OxyContin quickly became the most prescribed narcotic on Schedule II of the Controlled Substances Act (the most tightly regulated category of medication), with about 7.2 million prescriptions in 2001. It was a godsend for patients suffering from moderate to severe chronic pain, who could use it to get steady relief throughout the day.

Because some versions of OxyContin contained large doses of oxycodone (up to 160 milligrams), unmixed with analgesics such as acetaminophen or aspirin, it appealed to drug users looking for a handy way to get high. They discovered they could get all the oxycodone at once by crushing the tablets and snorting the powder or mixing it with water and injecting it. The crackdown triggered by such nonmedical use has made doctors wary of OxyContin. "While complete data for 2002 [are] not available," Purdue Pharma reports, "the growth in the number of prescriptions written has dropped compared to 2001." The government's response to OxyContin abuse also has increased doctors' apprehension about prescribing narcotics in general. The upshot is unnecessary suffering by patients who have trouble getting adequate pain treatment.

The consequences of an unreasonable aversion to narcotics, which pain experts call "opiophobia," can be severe, even deadly. In a May 2001 report to the American Society for Action on Pain (ASAP), a Kentucky physician said a former patient, a paraplegic with severe chronic pain, had killed himself. The man's new doctor, alarmed by official warnings about OxyContin, had drastically reduced his dose, leaving him in agony.

Skip Baker, ASAP's president, has collected petition signatures from thousands of pain patients concerned about the loss of effective treatment. "Many of them mention that they were taken off OxyContin because of the 'bad press' about it after having been on it for years," says Baker, who suffers from chronic pain caused by ankylosing spondylitis and fibromyalgia. "It has really been a crisis for us. Even my good pain doctor will not prescribe OxyContin, even though he knows it's the best pain medicine ever made. He admits that it's all because of how law enforcement's efforts have made it look so bad that doctors dare not prescribe it."

Looking Over Doctors' Shoulders

The negative publicity surrounding OxyContin has aggravated a longstanding problem. Beginning in the 1970s, studies repeatedly have found that pain is undertreated even in hospitals and nursing homes, even with patients on the verge of death. Last July an expert panel convened by the National Institutes of Health (NIH) confirmed that people with cancer still suffer needlessly from pain.

One member of the NIH panel, Dr. Paul Frame of Rochester University's School of Medicine, said restrictions aimed at preventing nonmedical use were partly to blame for the undertreatment of pain. "Sometimes doctors don't want to go to the hassle of prescribing a triplicate drug," he said at a press conference, referring to the special forms required by some states for strong painkillers. "They may decide to use something less effective instead."

In response to concerns about OxyContin abuse, states are monitoring painkiller prescriptions even more closely. Virginia, for example, does not require triplicate forms, but starting this year it will track prescriptions for Schedule II drugs electronically, with a special focus on OxyContin. Lawmakers such as Rep. Greenwood have suggested establishing a similar monitoring program at the national level.

Privacy concerns aside, such efforts deter legitimate treatment as well as diversion for nonmedical use because it is impossible to verify pain objectively.

Although physicians can take medical histories, check records, perform examinations, and do tests to confirm an injury or an illness, they ultimately have to decide whether to believe a patient who says he is suffering. Knowing that their judgment may be second-guessed by state or federal regulators, with consequences ranging from disruption of their practices to professional ruin, they naturally are reluctant to err on the side of trusting the patient.

"Pain patients are now treated like common street junkies when they turn to their local emergency rooms for help," says Tammy Alender, one of the patients who signed the ASAP petition. Alender, who suffers chronic back pain despite surgery aimed at correcting the problem, is anxious to get the word out that opioids must remain available to pain patients despite the potential for abuse. "They struggle to find adequate amounts of ongoing opiate medications to treat their valid conditions," she says. "To punish the masses of valid chronic pain patients just because of the actions of the few addicts out there is insane."

The American Pain Foundation estimates that 50 million people in the U.S. suffer from chronic pain, much of it undertreated. As of April 2002, the DEA counted 146 "verified" deaths involving OxyContin -- cases where OxyContin was the source of oxycodone found in someone's body but not necessarily the cause of death. Even in these cases, the subjects usually had taken alcohol or other drugs in addition to oxycodone. But let us accept the DEA's number for the sake of argument. The deaths it attributes to OxyContin over a period of two years represent just one-third of the deaths linked to acetaminophen in a single year. Yet the DEA has not declared Tylenol a "major drug of concern."

The Threat of Prison

To understand how the recklessness of a few OxyContin users can threaten the welfare of millions, consider the case of James Graves, a Florida physician who was sentenced in February 2001 to 63 years in federal prison. Graves was convicted of manslaughter and racketeering after four of his patients overdosed on OxyContin. It was the first time in U.S. history that a physician was found guilty of manslaughter for prescribing a self-administered medication that led to a patient's death. It probably won't be the last.

The racketeering conviction was based on the state's argument that Graves used his business for ongoing criminal activity by knowingly and recklessly prescribing opioids to patients without a medical purpose. Graves, who believes patients have a right to treatment for their pain, says he trusted their self-reports. His attorney, Michael Gibson, pleads a lack of technology to confirm the existence and severity of pain. "You can do an X-ray or an MRI," he says, "but it's very difficult to determine the level of pain. You might as well flip a coin looking at an X-ray."

Gibson says the DEA declined to get involved in the case because there was insufficient evidence of intent. He argues that the evidence to support the manslaughter charges was particularly weak. Two of the four patients were injecting OxyContin, which is never directed by prescription. Another took OxyContin prescribed by Graves as well as narcotics procured through his girlfriend. The fourth died of a multiple overdose including Xanax, Lortab, and a muscle relaxer as well as OxyContin. "Where does society assess fault?" Gibson asks. "When do you start making individual patients responsible for their actions?"

The prosecution argued that Graves was not sufficiently skeptical about his patients' reports of pain, and perhaps he wasn't. Patients who testified for the prosecution said they were not thoroughly examined. The prosecution also argued that Graves kept insufficient medical records, including notes on patient exams. But the precedent of a manslaughter conviction for what may have amounted to nothing more than excessive credulousness is apt to give pause even to doctors who are models of thoroughness. Gibson worries that the case will make doctors less likely to trust their patients, especially those with any history of addiction. He argues that "doctors should practice medicine, not law enforcement" -- a refrain echoed by patient advocates such as William Hurwitz and the National Migraine Association.

Graves' conviction may signal a trend toward holding doctors criminally accountable for their patient's self-inflicted injuries. In July 2001 West Palm Beach physician Denis Deonarine was charged with first-degree murder after one of his patients overdosed on OxyContin. Prosecutors argue that Deonarine is responsible for the death despite the fact that the drug was self-administered by a patient with a history of substance abuse whose body at the time of death contained significant levels of alcohol and tranquilizers as well as OxyContin. At least one other doctor in Florida and one in California face manslaughter charges based on their patients' OxyContin overdoses.

In addition to lax doctors, OxyContin critics blame the drug's manufacturer for marketing it too aggressively and not paying enough attention to its abuse potential. Thrown on the defensive by these charges, Purdue Pharma has been bending over backward to cooperate with regulators. In May 2001 the company suspended sales of its 160-milligram tablet, designed for patients with end-stage cancer. Two months later, it praised the FDA's intimidating new warning label and distributed a "Dear Healthcare Professional" letter to explain the change and highlight the risks of diversion and abuse.

The company also has promised to develop a more abuse-resistant formulation of OxyContin within the next three years. It is working on a version containing naltrexone, an opiate antagonist that would block oxycodone's euphoric effects once the pill was crushed. Although an abuse-proof alternative that retains OxyContin's effectiveness for treating pain has not yet been developed, some members of Congress want the FDA to require such a mechanism. So far the FDA has stood by its policy of approving Schedule II drugs without demanding that they incorporate antagonists. Such a requirement would further lengthen the drug approval process and could undermine the effectiveness of painkillers.

Hillbilly Heroin

The demands for immediate and drastic regulatory action are not surprising given the overheated press coverage of OxyContin abuse, which by the summer of 2001 had become the Next Big Drug Story. "It crept down the Appalachian Mountains from Maine to Alabama," began an August 2001 report in The Atlanta Journal-Constitution, "sending hundreds of victims to morgues, hospitals and rehab clinics." Time blamed OxyContin for "a blizzard of a crime wave" cropping up in "pockets of the nation." The Cincinnati Enquirer called it the "heroin of the Midwest." Florida's Port St. Lucie News dubbed it the "new crack." Other media outlets suggested "hillbilly heroin" and "poor man's heroin."

There was a measure of truth to some of these epithets. "This is an isolated area where it's hard for people to get real street drugs," says Phil Fisher, head of the Appalachian Pain Foundation, a West Virginia�based group trying to educate the medical community and public about the benefits of OxyContin. "OxyContin is not a street drug in most places." As a legal prescription medicine, OxyContin also may appeal to drug users who are leery of black-market heroin -- especially if they've seen the newspaper, magazine, and TV stories that describe how great the high is and explain how to achieve it.

A "former OxyContin abuser" interviewed by ABC in March 2002 said the drug gave him "an immediate warm feeling, feeling of well-being, almost -- I don't want to say godliness, but a feeling there's nothing I can't handle." A July 2001 New York Times Magazine story, "The Alchemy of OxyContin," put it this way: "As a pill it brings potent pain relief. As a powder it brings euphoria. It takes about five seconds to effect the transformation -- and not much longer to create an addict." Similarly hyperbolic reporting has been featured by other prominent media outlets, including Time, Newsweek, CBS, and even MTV, which aired "I'm Hooked on OxyContin" as an episode of its True Life series in 2001.

OxyContin was compared to heroin so many times that some people concluded it should be treated the same way. After James Graves' conviction, West Virginia state Sen. Truman Chafin suggested reclassifying OxyContin as a Schedule I drug, which would make it illegal for any purpose. Pain patients breathed a sigh of relief when other state officials, doctors, and pharmacists dismissed the idea. "To prevent terminally ill patients who are in need of legitimate pain management from obtaining a drug that effectively relieves their pain is not the answer," said the West Virginia Board of Pharmacy.

Yet increased scrutiny of prescriptions is bound to have a chilling effect on doctors' decisions about which patients to treat and how. In addition to monitoring at the state level, the DEA requested $24.6 million and 133 new positions for 2003 to strengthen its diversion control efforts. The agency has drawn up a "National Action Plan" targeting key sources of OxyContin and other opioids, including medical professionals it considers unscrupulous as well as doctor shoppers, prescription forgers, and pharmacy robbers.

"The growing national plague of Oxy addictions, overdoses, and deaths caused by the illegal activity of some doctors, pharmacists, and patients has been focused on like a laser beam by this office and other U.S. attorneys' offices," Gene Rossi, a federal prosecutor in Alexandria, Virginia, told The Washington Post in August. "If any person falls into one of those three categories, our office will try our best to root that person out like the Taliban. Stay tuned."

The menace depicted by drug warriors like Rossi bears little resemblance to the medicine that helps patients keep agony at bay. Thomas Rogers, for instance, is a healthy 31-year-old man -- healthy, that is, except for the degenerative disc disease that gives him chronic back pain. He has opted to forgo spinal lumbar fusions, which would involve the removal of natural discs and the insertion of rods or screws in his back, in the hope that a less invasive procedure will soon be available. His pain has been treated effectively with OxyContin by an Atlanta-based physician for three years.

"I would give anything to have a healthy, strong back like most 31-year-olds have," Rogers says, "but this is the way things are for me, and thankfully OxyContin has given me some sort of a life since I've been taking it....As long as I have a good doctor who understands and science can produce meds like OxyContin, life is livable. I could not live with the constant pain in my lower back without the benefits of this drug."

Gerald M. Aronoff, medical director of the North American Pain and Disability Group, has written several books and articles about chronic pain management. In his view, OxyContin is an excellent sustained-action opioid that has gotten a bad rap. "We're in a mode where everyone's picking on opioids," Aronoff says. "They are not terrible drugs....They have a wider margin of safety than the nonsteroidal anti-inflammatory drugs" such as acetaminophen and ibuprofen, because they carry less risk to the liver and the gastrointestinal tract. Removing them from the market would mean a "major step backward in our ability to manage pain," he says.

Addicted to Pain Relief

Much of the concern about OxyContin stems from a misunderstanding of addiction. Aronoff observes that people mistakenly equate addiction with tolerance (the need for higher doses to achieve the same effect) and so-called physical dependence, changes in the body that lead to withdrawal symptoms if the drug is abruptly withdrawn. Anyone who takes an opioid like OxyContin every day will eventually develop tolerance and physical dependence, but addiction requires an attachment to the drug's psychoactive effects. "Addiction is characterized by the repeated, compulsive use of a substance despite adverse social, psychological, and/or physical consequences," says Aronoff. "Addiction is often, but not always, accompanied by physical dependence, withdrawal syndrome, and tolerance."

Conversely, people who take OxyContin and other opioids for pain may develop tolerance and physical dependence, but that doesn't mean they're addicted. Several studies conducted during the last few decades have found that patients who receive narcotics for pain rarely end up seeking the drug for nonmedical reasons. "One study found that only 4 out of about 12,000 patients who were given opioids for acute pain became addicted," the National Institute on Drug Abuse reports. "In a study of 38 chronic pain patients, most of whom received opioids for four to seven years, only two patients became addicted, and both had a history of drug abuse."

Geov Parrish, a Seattle-based writer who has been taking OxyContin for seven years, pokes fun at the confusion about addiction perpetuated by media hype. "OxyContin is a narcotic, and I am 'addicted' to it, in the sense that if I don't take it I'd get nasty withdrawal symptoms," he writes on WorkingForChange.com. "In terms of whether my body would be unhappy if I didn't ingest it, I'm also 'addicted' to a number of other prescribed drugs, and to food, water, oxygen, and my sweetie. Addiction is an overrated concept."

Parrish says he tried various pain medications after an organ transplant left him with debilitating pain, but oxycodone is the only one that works. "If I weren't on it, I couldn't function from day to day," he writes. "And for many, many people with cancer, AIDS, and other serious ailments, it's the difference between a relatively normal life and day after day of pure hell."

Thomas Rogers concedes that his 12-hour OxyContin dose has doubled, from 10 to 20 milligrams, since he began taking the drug three years ago. He is also well aware that he would have to go off OxyContin gradually to avoid withdrawal symptoms. But he doesn't consider himself an addict. "People like me who suffer every day aren't concerned about addiction or being labeled as druggies," he says.

"We just want out of pain, and OxyContin will do it when we are being treated by good doctors. Is a diabetic person who is dependent upon insulin considered an addict? Are people who take OxyContin any different? We depend on a drug to help our pain so that we don't get depressed and suicidal. I personally don't like waking up every single morning hurting and knowing that it may very well be this way the rest of my life."

Rogers resents anti-OxyContin crusaders who gloss over or ignore the drug's benefits for pain patients like him. "Their backs probably don't hurt," he says. "No matter what kind of drug is ever produced, there will always be people who will abuse it and give it a bad name. These people never represent the thousands of legitimate patients like me who are not addicted but depend on it for some kind of life, as pain-free as possible."

Breast Men

melindaammann@hotmail.com (Melinda Ammann) — Mon, 01 Jul 2002 00:00:00 EDT

Amador Anchondo-Rascon speaks in a low, soft voice, switching so fluidly from English to Spanish that I'm surprised when I suddenly don't understand what he's saying. Although he has lived in this country for more than two decades and speaks fluent English, he gives the impression that he's more comfortable speaking the Spanish he grew up with in Cuauhtemoc, Mexico. Wearing a bright orange jumpsuit, he sits at a table in a Chattanooga, Tennessee, jailhouse, speaking with small gestures of his cuffed hands and fiddling with an invisible cigarette. He swears he doesn't smoke or drink, but he will admit to helping friends and relatives cross the border illegally.

Anchondo-Rascon is a soft-spoken family man, a community leader, and a felon. He has spent most of the last two years in jail, first in Texas, then in Tennessee, both times charged with transportation of illegal aliens. The latest charges also include conspiracy to provide false documents. He pleaded guilty to these charges as part of an agreement with federal prosecutors that will cap his sentence at five years in exchange for his testimony against Tyson Foods and six current and former employees of the company.

Because Anchondo-Rascon is a key witness in a case much larger than his own, he hopes he will be able to strike a bargain that lets him return to his life in Shelbyville, Tennessee, where he and his wife, Robertina, own and operate a Hispanic grocery store. At best, he may be able to go home after being sentenced to time served. At worst, he may be deported to Mexico. (A sentencing hearing was scheduled for May 20.)

According to an indictment filed last December in U.S. District Court in Chattanooga, Tyson Foods made a regular practice of hiring illegal aliens for several plants, including a fresh chicken processing plant in Shelbyville. Anchondo-Rascon allegedly acted as a recruiter of immigrants for the plant, working with Tyson managers to maintain a flow of employees from Mexico. The plant always needed laborers, and there was a steady supply of immigrants who were ready and willing to take the jobs. Since the indictment against Tyson, about 200 immigrants have lost their jobs at the 1,200-employee Tyson plant in Shelbyville, a town with a population of about 16,000.

The indictment of the world's largest poultry producer on charges that it conspired to import undocumented laborers has brought renewed attention to the immigration problem -- not the problem of religious zealots with bombs in their shoes but the lower-profile one posed by millions of people who come to the United States to do our dirty work. The Bush administration has pushed Congress to extend a program that makes it easier for some of these people to get resident alien ("green") cards, and the president has signaled that he may be open to a broader amnesty for illegal immigrants or an expanded guest-worker program. But the Tyson case, which has received national attention, makes it clear that many people -- Americans and Mexicans, powerful executives and poor immigrants -- feel they can't afford to wait for changes in the law.

Model American

Anchondo-Rascon's story is like those of many who have come to the U.S. from Mexico in search of a better life. After years of hard work and perseverance, he managed to buy a house, start a business, and raise a family. His entrepreneurial instincts also drew him to a market niche created by immigration laws that block the free flow of human capital.

In 1979 Anchondo-Rascon, then 21, walked across the border into New Mexico. He walked 240 miles through the desert, a trip that took about 10 days. He left a job that paid well by local standards, in a Mexican oil refinery where he made $20 to $30 a week. When he arrived in the U.S., he began hoeing cotton and doing irrigation work in New Mexico for $35 to $40 a day. He moved to Florida before settling in Tennessee, where he has lived since 1986. He worked in the tree nurseries in McMinnville with his brother until he heard about the better-paying jobs at Tyson.

The Tyson Foods plant in nearby Shelbyville hired Anchondo-Rascon in 1989 to debone and pack chicken. He worked hard and was promoted to supervisor. In 1995 Anchondo-Rascon figured that his little town, where Latino immigrants were pouring in, was ripe for a Hispanic grocery store. He left Tyson to open Los Tres Hermanos with $1,500 in savings. When the store opened, corn flour for making tortillas was its sole product, but it quickly grew to offer a wide range of Hispanic groceries, music, and other imports. Anchondo-Rascon's brother-in-law opened a similar store in McMinnville.

Shelbyville lies in Bedford County, Tennessee, which has about 38,000 residents, 7.5 percent of them Latinos. From 1990 to 2000, the county's Hispanic population grew by 1,500 percent. Bedford County is a microcosm of immigration from Mexico, the leading source of both legal and illegal immigrants to the U.S. In addition to the 91,000 legal Mexican immigrants who arrive each year, the Census Bureau estimates there are nearly 4 million illegal Mexican immigrants in this country.

The flow of immigrants from south of the border has changed the face of Shelbyville. Los Tres Hermanos, which serves as an orientation center for newcomers as well as a grocery store, has been a part of that transformation. As an interpreter, Anchondo-Rascon was invaluable to those who needed to go to court, translate documents, or get license plates, and he became a leader in the Hispanic community. He maintained friendly ties with proprietors of various businesses in town, such as Celebration City Motors, where he bought a car when he first arrived. Anchondo-Rascon developed a good relationship with the owner by paying off his debt ahead of schedule, and he recommended newcomers he considered good credit risks to the car dealership, which was happy to have the business.

Hispanic immigrants to Shelbyville, who included Guatemalans as well as Mexicans, had no problem finding work. Most were hired by the town's largest employer, Tyson, where about half the current work force is Hispanic. They didn't need to speak English well to work on the line processing chicken, and the pay, which was higher than minimum wage and included health insurance, was better than the pay in pencil manufacturing, the other dominant local industry.

The Hispanic influx continued unabated throughout the 1990s, but it abruptly reversed after an 18-month investigation by the Immigration and Naturalization Service (INS) culminated in a 36-count indictment against Tyson in December 2001. Since the indictment, hundreds of Hispanics have left Shelbyville, having lost their jobs or fearing deportation. Amador Anchondo-Rascon has landed in jail, while his worried wife tries to keep the family business going.

Bill Logue, the Shelbyville officer who handles most police business with the local immigrant population, arrested Anchondo-Rascon in July 2000. He was acting on behalf of the U.S. Border Patrol, which wanted the grocer on immigrant-smuggling charges unrelated to the Tyson case. Logue had seen increasing numbers of immigrants presenting false documents in traffic stops and investigations of domestic disturbances. He had a couple of leads that made him suspect Anchondo-Rascon. When asked where they got false documents, some immigrants would mutter "Los Tres Hermanos."

In 1998 an immigrant caught with fake identification during a traffic stop agreed to help police collect evidence against Anchondo-Rascon. The man walked into Los Tres Hermanos wearing a police wire and asked if he could get a Social Security card and a resident alien card. Anchondo-Rascon told the man he should come back with a photograph and $200. The whole process took a couple of weeks, longer than usual.

Logue, a Shelbyville police officer for 13 years, says violent crimes remained steady during the influx of Hispanic immigrants, while misdemeanor offenses such as driving under the influence and hit-and-run collisions increased. "They learned that in Mexico if they hit someone and called the police, the police would beat them up or extort money from them," he says. Mexicans learn to view government authorities, including local police officers, more as abusive antagonists than public servants.

The most serious crimes to increase have been forgery and ID theft, both of which carry felony charges. Most immigrants arrested with false documents face such charges, but "99.9 percent" of them, according to Logue, are downgraded to misdemeanor charges because the courts simply cannot process that many felonies. Besides, the individual with false documents is not the law's main concern. "I'm not interested in prosecuting the little guy who comes across the border to build a better life," says Logue. Although he believes nearly all the immigrants who get false papers know they're breaking the law, the people he really wants to nab are the middlemen who provide false documents to the little guys.

Faked Out

You get what you pay for when purchasing false documents. A Social Security card or green card can be procured for as little as $100. Some are obvious fakes to anyone who's seen the genuine article before. A well-forged birth certificate and Social Security card may cost up to $1,500. Most of the Social Security cards Logue has seen are forged with numbers in a series not yet issued by the Social Security Administration (SSA), so a familiarity with issued numbers and a simple check reveal them as fakes. Better are cards with "good" numbers -- ones already issued by the SSA to other individuals -- that are stolen, purchased, or forged.

Matthew Baez of Esperanza del Barrio, a nonprofit group that provides social services for the Hispanic community in Chattanooga, says most undocumented Hispanic immigrants start cheap and trade up. A first set of documents might cost $100 and will be good enough to get a job in dry cleaning, landscaping, or construction. After a few weeks or months, an immigrant will have saved enough money to purchase higher-quality documents that will help him or her secure a better job.

Social Security cards with good numbers pass the scrutiny of screening systems, such as the one used by Tyson Foods, designed to catch illegal immigrants presenting false papers. Tyson claims to be one of the first large companies to use INS-provided software called the Employment Eligibility Verification Program, a.k.a. the Basic Pilot Program, to filter illegal immigrants out of its work force. Tyson started using the program in 1996.

According to the indictment against Tyson, "If the document, such as a Social Security card or a green card, provided by the employee was counterfeit but contained a true Social Security number or alien registration number issued to a real person of that name (even though the person supplying the card was an imposter and not the person stated on the card) it would pass the EVP/Basic Pilot Program, even though the card was counterfeit and was obtained illegally, as the defendants and the other coconspirators then and there well knew." The indictment quotes defendant Truly Ponder, former complex manager at Tyson's Shelbyville operation, saying to an INS undercover agent while arranging for new immigrant employees that applicants must provide documents that will "in the computer...look like they're good [Social Security] numbers."

Another defendant, Spencer Mabe, former complex personnel manager and former plant manager in Shelbyville, is quoted as saying to an INS undercover agent posing as a recruiter, "We can pay you $100 a head....All I need to know, a guarantee these people are going to stay a while....But I need about 15. Quick as you can. They're able to go through the computer, right?" The INS agent responded that his friend in California had "been getting some numbers....He probably, you know, can give me a good deal...good numbers." Mabe replied, "I understand that if they go through the [Tyson] computer like you said, there will be no questions asked on my end."

Finder's Fee

According to the indictment, Anchondo-Rascon would receive a "recruitment fee" of $200 per employee. He had to guarantee that the applicant's Social Security number would pass muster and that he would work at Tyson for at least six months. If the employee left early, Anchondo-Rascon would have to supply a replacement.

Another method by which Tyson allegedly conspired to hire illegal immigrants was by arranging for temporary workers to fill full-time slots without full-time benefits. The temp agencies did not use the Basic Pilot Program, and the indictment charges that Tyson knew many of the workers were not authorized for employment in the U.S.

Ironically, since the indictment for conspiracy to hire illegal immigrants, Tyson has been put on notice by another division of the Department of Justice for being too scrupulous in checking the legal status of immigrant applicants. The DOJ's Civil Rights Division sent letters to Tyson in May 2000 and January 2002 regarding its inquiry into allegations that the company's plants in Sedalia, Missouri, and Noel, Missouri -- both of which are named in the conspiracy indictment -- discriminated against immigrants by scrutinizing their employment verification documents too closely. It seems Tyson is damned if it does and damned if it doesn't.

Tyson says it highly values the Hispanic immigrants who work at its plants. These immigrants are essential to the daily operations that put dinner on tables across America. Rebutting the claim that immigrants take jobs away from American workers, Tyson spokesman Ed Nicholson says immigrants make up a substantial proportion of the company's work force only where unemployment is very low. He points to Tyson's Pine Bluff, Arkansas, plant as an example of a site where few immigrants work because the unemployment rate is relatively high, so local people take the jobs. In general, he says, "The Latino work force is not competing with the local available work force; they're augmenting it. Anybody who wants to work can work."

And here is where the crux of the INS's real problem lies. The U.S. demand for laborers is simply too high for Hispanic immigration to stop or even slow down. Anchondo-Rascon's attorney, Michael Friedman, who has represented many Latino immigrants, observes that getting a U.S. work visa in Mexico is a long and harrowing process. "If it was easy to do -- if it was possible to do -- believe me, they wouldn't be risking their lives to come here," he says.

Undocumented immigrants flow northward through a dangerous underground railroad, paying "coyotes" to escort them through the desert and past the Border Patrol's checkpoints. After they leave loved ones behind, pay anywhere from a few hundred to a few thousand dollars, and endure the physically demanding trip, there is still no guarantee of success, as Anchondo-Rascon can attest. He was caught and escorted back to Mexico by the Border Patrol the first time he made it to the U.S., when he was 16. But working through the legal process to be documented and immigrate legally is often an even more frustrating, expensive, and time-consuming process, also without assurance of success. As long as there are jobs to be had and workers south of the border making less than they can in the U.S., there will be immigration, whatever the law says.

"If there aren't jobs, people won't come," says Paul Portland, a Catholic priest in Shelbyville. "The jobs that the illegals do, the people here don't want to do. It's hard work....Ask anyone who employs Mexican workers -- they're happy."

Portland came to Shelbyville a couple of years ago to lead St. William's Catholic Rectory. The diocese realized the little town needed a bilingual priest to serve the growing Hispanic population, about 95 percent of which grew up Catholic. The church offers four services during the week: two in English, one in Spanish, and one in both languages. As a bilingual leader of his congregation, Portland offers more than religious services. "I go to the hospital, to the doctor, to the drug store with people," he says.

The town lacks a social infrastructure for the Hispanic community, Portland says, and this contributes to immigrants' vulnerability, whether they have genuine documents or not. Services that Americans take for granted are daily struggles. Many who speak only Spanish save their money under the mattress because they don't trust banks or don't know how to communicate with bankers. They don't always report crimes when they are victimized or get medical care when they need it. Portland says the town needs more bilingual lawyers, doctors, firefighters, and police.

Portland scoffs at the notion that Hispanic immigrants come to this country to take advantage of government-sponsored social services. "People say they're not paying taxes, but that's baloney," he says. "They're paying sales tax. They're paying Social Security taxes, and they'll never see any of that. If they're illegal, they can't get it back."

Portland, who interacts daily with illegal immigrants, follows a "don't ask, don't tell" policy with his congregants. "They'd rather be at home, but they can't live there," he says. "People want jobs. People want to give jobs. We ought to find a way to let that happen where people aren't so vulnerable."

Tyson is charged with preferring illegal immigrants to documented workers because employees afraid of arrest and deportation are willing to put up with poor working conditions. The company is accused, for example, of giving illegal workers fewer bathroom breaks and forcing them to be more productive by moving conveyor belts faster. Illegal workers were less likely to complain to management, file a grievance with government agencies, seek workmen's compensation benefits, or be absent from work.

Villains or Victims?

Officer Logue believes intermediaries such as Amador Anchondo-Rascon are taking advantage of illegal immigrants. He sees them as ruthless gangsters who profit from the desperation of the undocumented. But Anchondo-Rascon can also be seen as another victim, a pawn in a high-stakes game that's played on a much larger scale than a small-time "crook" like him could imagine. Tyson has made millions in profits -- $100 million, according to an INS estimate -- with the help of hard-working immigrants who might not be in this country without Anchondo-Rascon's help. His thanks: the threat of deportation to the country he began struggling to escape as a teenager.

The INS makes Tyson out to be the bad guy: a big corporate bully anxious to hire illegal immigrants because they will work harder for longer hours and accept substantially less pay than legal residents or U.S. citizens. But those who understand how markets work may not be so quick to condemn Tyson. As the indictment emphasizes, the company desperately needed workers for jobs that most Americans won't take. Someone has to do the dirty work of transforming a live bird into a boneless, skinless chicken breast.

Undocumented Opportunity

Most Americans probably would not fault the undocumented immigrants themselves for making the hard choice to come to the U.S. After all, they simply want to work and build better lives for their families. They're more than willing to travel thousands of miles, work backbreaking shifts six or seven days a week for meager pay, and send a good deal of their earnings home in order to slowly piece together their own American dream. Most of the immigrants who have left Shelbyville since the Tyson indictment are not headed back to Mexico. They are still looking for better opportunities.

Friedman, Anchondo-Rascon's attorney, says he hopes the Tyson case will spur the government to take "the action that President Bush and [Mexican] President [Vicente] Fox outlined in August to document these workers -- give them status, give them recourse, and protect them." Last summer a White House task force on immigration headed by Secretary of State Colin Powell and Attorney General John Ashcroft went so far as to suggest amnesty for the 4 million or so undocumented Mexican immigrants living in the U.S. When he met with Bush last August, Fox pressed for reform by the end of the year. Then came the attacks of September 11.

Some Republicans have always seen amnesties for undocumented workers as undeserved rewards to people who manage to get away with breaking laws that others patiently obey. Since last fall these opponents have been joined by others who cite terrorism as a reason to be leery of any effort to liberalize immigration policies. (Never mind that terrorists from Mexico do not loom large as threats to U.S. security.) After the House of Representatives voted in March to extend an existing program that allows undocumented workers with relatives in the U.S. to seek green cards without leaving the country, Sen. Robert Byrd (D-W. Va.) promised to block a vote on the measure in the Senate. "It is lunacy -- sheer lunacy -- that the president would request, and the House would pass, such an amnesty at this time," he said. Bush hoped to bring an extended visa program for Mexicans living in the U.S. to the table when he met with President Fox in late March, but the House-approved measure remained stalled in the Senate.

While it may be slow in coming, the prospects for reform are better than they've been in recent memory. Bush seems to understand and embrace the simple idea that Mexicans deserve economic opportunity -- in the sense of freedom to engage in voluntary, productive exchange -- as much as anyone born north of the Rio Grande. As White House spokesman Ari Fleischer said at a press conference last summer, "There are people who are already in this country, contributing to the American economy, even though they may not be legal, and they are paying taxes. As a result of their labor and their efforts, Americans are able to enjoy many aspects of life....The president wants to make certain that if there is a willing employer who needs a willing worker, we have immigration policies that respect that arrangement."

Anchondo-Rascon hopes to return to Shelbyville and rebuild business at Los Tres Hermanos, which has been slumping since his arrest. He still believes in the Land of Opportunity. "I think America is the greatest country in the world," he says. "We have to work seven days a week, 10 hours a day, but that's OK -- as long as we have a good future for our family."